Provider Demographics
NPI:1225395023
Name:LIVEWISE LLC
Entity Type:Organization
Organization Name:LIVEWISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:502-510-3630
Mailing Address - Street 1:103 ENGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2520
Mailing Address - Country:US
Mailing Address - Phone:502-510-3630
Mailing Address - Fax:
Practice Address - Street 1:103 ENGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2520
Practice Address - Country:US
Practice Address - Phone:502-510-3630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-14121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty